Severe Bullous Pemphigoid Onset after Jugular Catheter Placement in a Patient on Hemodialysis.

Pruritus is highly prevalent in the dialysis population. Its etiology however remains often unclear with uremic pruritus primarily suspected unless compelling evidence of another cause. Although bullous pemphigoid (BP) is considered idiopathic, there are growing data in the literature on BP provoked by different factors, such as medications or surgical procedures. These secondary dermatoses are described as rather mild conditions and more frequent in the elderly Caucasian. We herein describe a newly dialyzed African man of 76 years old, treated by a sulfonylurea such as an antidiabetic drug, who developed a severe BP after jugular catheter placement.

Childhood granulomatous periorificial dermatitis: case report and review of the literature.

Childhood granulomatous periorificial dermatitis (CGPD), considered a clinical variant of perioral dermatitis, typically affects prepubertal children of African descent. It is a condition of unknown etiology characterized by the presence of a monomorphic yellow-brown papular eruption limited to the perioral, perinasal, and periocular regions that histopathologically shows a granulomatous pattern. This disorder should be differentiated from other conditions as granulomatous rosacea, sarcoidosis, and lupus miliaris disseminatus faciei. We report a case of a 9-year-old boy who presented with flesh-colored perorificial papules on the face, evolving for two months. Upon treatment with topical tacrolimus for follicular eczema, an aggravation of the condition was observed. A skin biopsy confirmed the diagnosis of CGPD. Our patient was successfully treated with a combination of topical metronidazole and topical erythromycin.

Acne fulminans induced by a low dose isotretinoin: case report and review of the literature.

Acne fulminans is a rare complication of classic acne. Less than 200 cases have been reported. It usually affects adolescent males with pre-existing acne vulgaris. It is characterized by an acute eruption of numerous and large inflammatory nodules, plaques, erosions, and ulcers covered by hemorrhagic crusts. The disorder may occur spontaneously or may be triggered by isotretinoin. We report a young boy who developed acne fulminans after isotretinoin therapy at a dose of 0.1mg/kg/day. A systematic literature review gathering previously reported cases on PubMed revealed that one similar case has been reported. Regarding therapeutic strategies, there are no randomized clinical trials to identify the best treatment for acne fulminans. Recommendations are based on case series and case reports. We share this case to raise awareness of the induction of acne fulminans by a very low dose of isotretinoin.

Pityriasis rubra pilaris as a systemic disease.

Pityriasis rubra pilaris (PRP) is a rare inflammatory skin disorder of unknown etiology, initially described in 1835. It is characterized by keratotic follicular papules, well-demarcated salmon-colored erythematous scaly plaques interspersed with distinct islands of uninvolved skin, and palmoplantar keratoderma. Is PRP a systemic disease? Skin is mainly affected in PRP. Despite its clinical heterogeneity, PRP could be associated with a variety of rheumatologic, infectious, neoplastic, and other extracutaneous manifestations. We accept the hypothesis of not only an association but also a causative relation between skin and systemic manifestations with possible common underlying pathomechanisms such as systemic immunologic processes and superantigen mimicry.

Tuberculosis-related type of psoriasis.

Psoriasis is a multifaceted disease in terms of its pathophysiological mechanisms, inducing and aggravating factors, clinical types and clinical severity, associated comorbidities and therapeutic modalities. In recent years, an attracting perspective has emerged to identify variants of the disease with their own specific clinical course and management which could stratify the variable spectrum of the disease into different entities (such as palmo-plantar pustulosis). We hypothesize the existence of a unique Tuberculosis-related type of psoriasis that could be managed successfully with rifampicin.

Psoriasis as a systemic disease.

Psoriasis is an inflammatory immune-mediated disease that affects the skin and has pathogenic effects with systemic impact. The relationship between psoriasis and comorbidities remains controversial. The hypothesis of a causative role of psoriasis in its cardiovascular and metabolic comorbidities is based on pathophysiologic concepts establishing a link between chronic inflammation in psoriasis, endothelial dysfunction, formation of atherosclerotic plaques, and the different compounds of metabolic syndrome. Psoriasis management has to be multidisciplinary. It implicates identification and treatment of psychological disorders, addictions, and associated cardiovascular and metabolic diseases, together with improvement of quality of life of patients.

Psoriasis and cardiovascular risk factors: increased serum myeloperoxidase and corresponding immunocellular overexpression by Cd11b(+) CD68(+) macrophages in skin lesions.

BACKGROUND: Recent studies report independent associations between psoriasis, cardiovascular (CV) events and risk factors. Blood Myeloperoxidase (MPO) from activated myeloid cells is associated with CV risk mainly through lipid oxidation, induction of endothelial dysfunction and release of IL-12 from macrophages. OBJECTIVES: To elucidate associations between psoriasis and conventional CV risk factors. METHODS: We performed a cross-sectional study of 100 psoriasis patients and 53 controls, group matched on age, gender and body mass index, to assess levels of MPO in serum, as well as immunohistochemical staining from psoriasis skin lesions, psoriasis uninvolved skin, and normal skin. RESULTS: Although the groups did not differ on waist circumference, glucose, cholesterol, triglycerides, creatinine or personal history of CV events, psoriasis patients had significantly higher waist-to-hip ratios, blood pressures, proportion of current smokers, and lower high density lipoprotein level than controls. Serum MPO level was elevated 2.5 fold (P<0.001) in psoriasis patients, even after adjusting for the CV risk factors on which the groups differed. MPO did correlate with coronary artery calcification, carotid plaque, carotid intima media thickness and flow mediated dilation, but did not correlate with psoriasis severity. However, MPO was highly expressed in lesional psoriatic skin and colocalized predominantly with CD45(+) CD11b(+) leukocytes. CD11b(+) cell density correlated with circulation MPO levels. CONCLUSION: Lesional skin CD11b(+) leukocytes activated to generate MPO may contribute to serum levels of MPO. Lesional CD11b(+) cell activity may be an alternative measure of disease burden to PASI that underlies the MPO biomarker for systemic inflammation related to Cardiovascular Disease.

Physical and mental impact of psoriasis severity as measured by the compact Short Form-12 Health Survey (SF-12) quality of life tool.

The Short Form-12 Health Survey (SF-12) is used to assess the patient's quality of life (QoL) using the physical component score (PCS) and the mental component score (MCS). The purpose of this study was to determine whether the SF-12 PCS and MCS are associated with psoriasis severity and to compare QoL between Murdough Family Center for Psoriasis (MFCP) patients and patients with other major chronic diseases included in the National Survey of Functional Health Status data. We used data from 429 adult patients enrolled in MFCP. Psoriasis Area Severity Index (PASI) was used to assess psoriasis severity at the time of completion of the SF-12 questionnaire. Other variables included age, sex, body mass index, psoriatic arthritis, psychiatric disorders, and comorbidities. Linear regression models were used to estimate effect sizes ± 95% confidence intervals. For every 10-point increase in PASI, there was a 1.1 ± 1.3 unit decrease in MCS (P=0.100) and a 2.4 ± 1.3 unit decrease in PCS (P<0.001). Psoriasis severity was associated with PCS and MCS after adjusting for variables, although the strength of the relationship was attenuated in some models. Psoriasis severity is associated with decreased QoL. SF-12 may be a useful tool for assessing QoL among psoriasis patients.

Elimination of autoreactive B cells in humanized SCID mouse model of SLE.

Although the exact etiology of systemic lupus erythematosus (SLE) remains elusive, B-cell hyperactivity and production of autoantibodies directed to components of the cell nucleus are a well-established pathogenetic mechanism of the disease. Therefore, the targeted inhibition of DNA-specific B cells is a logical therapeutic approach. The complement receptor type 1 (CR1, CD35) has been shown to suppress human B-cell activation and proliferation after co-cross-linking with the BCR, and may serve as a mediator for negative signal delivery. In order to evaluate this therapeutic approach in a human-like system, we used immune-restricted SCID mice transferred with PBMCs from SLE patients. The tolerance of these humanized SCID mice to native DNA was re-established after administration of a chimeric molecule consisting of a CR1-specific mAb coupled to the decapeptide DWEYSVWLSN that mimics dsDNA. The generated protein-engineered chimera was able to co-cross-link selectively native DNA-specific BCR with the B-cell inhibitory receptor CR1, thus delivering a strong inhibitory signal.

Psoriasis treatment patterns of dermatologists in northeast Ohio.

AIM: To describe the psoriasis treatment patterns of community-based dermatologists in northeast Ohio. MATERIALS AND METHODS: A prospective cross-sectional survey was performed among dermatologists in northeast Ohio. The survey was initiated by the Murdough Family Center for Psoriasis and members of LIFEDERMNET (Leaders Initiative For Excellence In Dermatology Network). A questionnaire was sent to all community-based dermatologists in northeast Ohio. RESULTS: Forty-seven of 145 questionnaires were returned and analyzed. The annual mean number of psoriasis patients seen in the community-based dermatology practices was 250, representing approximately 4% of the total patients seen. Among the systemic treatment options for psoriasis, each of the following was used at least once to treat a patient with psoriasis in the previous year by the following percentage of community-based dermatology practices: methotrexate, 72%; acitretin, 68%; biologics, 66%; phototherapy, 55%; cyclosporine, 36%; and the excimer laser, 28%. CONCLUSION: Our findings demonstrate that dermatologists in northeast Ohio use both systemic and biologic agents for the treatment of patients with psoriasis.

Psoriasis in the elderly: from the Medical Board of the National Psoriasis Foundation.

BACKGROUND: The continuous increase in the US population older than 65 years and the chronic course of psoriasis make management of psoriasis in the elderly an important health care problem. OBJECTIVE: We sought to develop a treatment algorithm for patients with psoriasis who are older than 65 years. METHODS: A systematic literature search for studies on elderly patients with psoriasis was performed using MEDLINE. RESULTS: We summarize the available published data on therapeutic modalities used in the elderly. We suggest a treatment algorithm including topical medications as first-line treatment for limited disease, with phototherapy, systemic retinoids, methotrexate, and biologics as the first-line systemic treatments for patients with more extensive disease. Cyclosporine should only rarely be used as a second-line systemic treatment for extensive disease in elderly patients with psoriasis. LIMITATIONS: Limited data are available regarding treatment modalities specifically for elderly patients with psoriasis. CONCLUSION: Appropriate treatment for elderly patients with limited psoriasis includes topical corticosteroids, topical vitamin D analogues, and topical tazarotene. For appropriately monitored elderly patients who have psoriasis with extensive disease, phototherapy, acitretin, methotrexate, alefacept, etanercept, adalimumab, infliximab, and ustekinumab are first-line therapies that can generally be safely used. There remains a need for further research on the management of psoriasis in elderly patients with psoriasis.

Rifampicin--a mild immunosuppressive agent for psoriasis.

The immunosuppressive properties of rifampicin have been discussed in the literature for more than 30 years. It is hypothesized that rifampicin acts as a mild immunosuppressive agent in psoriasis rather than an antibacterial one. We report our studies on the therapeutic efficacy of rifampicin in guttate psoriasis. We try to give light on the mechanism of action of rifampicin in psoriasis. Our therapeutic results together with data from the literature revealed rifampicin to be a mild immunosuppressive agent. Its best effectiveness is in the guttate type of the disease.

Incidence of Parkinson's disease in Bulgaria.

The incidence of Parkinson's disease (PD) was studied over a 3-year period (2002-2004) in the district of Plovdiv, Bulgaria with a mean population of 713,090. Of 663 possible cases, 244 patients diagnosed with PD were included in the study. The diagnosis PD was based on UK PD Society Brain Bank Criteria. The average crude incidence rate of PD was 11.44/ 100,000 person-years. After age adjustment to the general Bulgarian population, incidence was 11.65/100,000: 17.46 for men; 7.24 for women; 12.97 for the urban group and 9.55 for the rural group. Age-specific incidence was 0.67/100,000 in the age range 40-44, reached a maximum of 112.73/100,000 for males and 52.58/100,000 for females in the age range 75-79 years and declined in the elderly. The present study estimates the incidence of PD in Bulgaria, which is similar to that in other European countries. The incidence rate in the Bulgarian population is twofold higher in men compared to women and slightly higher in the urban population compared with the rural population.

Climatotherapy of psoriasis.

In the era when biological treatments for psoriasis are gaining more and more popularity, climatotherapy represents a safe and efficient alternative to the conventional therapeutic modalities. Climatotherapy comprises alternative treatment methods, which are based on the healing capacities of natural resources. This paper provides the reader with relevant information on the different climatotherapeutic methods, the intimate mechanisms of their action, and the cumulated clinical experience in the treatment of psoriasis. The positive effect of thalassotherapy for psoriasis has been known since ancient times. However, in the past decades a number of controlled studies revealed the efficacy of thalassotherpay in the treatment of psoriasis. Herein, it is exemplified on the experience in the centers at the Dead Sea and the Black Sea coast. Originating from Europe, balneo- and spa therapy are becoming popular alternatives for psoriasis treatment worldwide. A short review on the centers profiled for psoriasis therapy is provided. The unique sites of Blue Lagoon in Iceland and Kangal in Turkey are selected in this paper. Additionally, alternative nature-based treatments for psoriasis such as high mountain climatotherapy and naphtalotherapy are discussed.

Toxic epidermal necrolysis as a dermatological manifestation of drug hypersensitivity syndrome.

Drug hypersensitivity syndrome (DHS) is believed to be an adverse idiosyncratic drug reaction associated mainly with administration of aromatic antiepileptic drugs, such as phenytoin, carbamazepine, phenobarbital, lamotrigine. The syndrome is defined by the clinical triad of fever, skin rash and internal organ involvement and can be life-threatening condition. We describe three patients treated in our institution. The first was a 32-year-old man who developed toxic epidermal necrolysis (TEN) with pulmonary and liver involvement after initiation of lamotrigine therapy for concomitant epilepsy. The second 32-year-old man was treated with salazopyrine and omeprazole in order to relief the symptoms of inflammatory bowel disease, but as a result developed toxic epidermal necrolysis with elevated liver enzymes. The third patient was a 28-year-old man with long history of alcohol abuse who began treatment with carbamazepine and a few days later he was admitted to the clinic with symptoms of severe disseminated skin rash. The patients had peripheral eosinophilia. All the patients needed urgent life-saving therapy, intensive care and nursing. The culprit drug was discontinued and prompt systemic therapy with corticosteroids at an initial dose of 2 mg/kg/d and with broad spectrum antibiotics was started. Topical therapy included spraying Avène thermal water and local antiseptics. Resolution and epithelization of skin erosions were observed in about 4 weeks after the initiation of the therapy. Medications can give rise to certain adverse reactions including serious cutaneous and systemic involvement. TEN is a rare complication of DHS. Patients who develop DHS need optimal and adequate treatment. The concomitant use of corticosteroids and broad spectrum systemic antibiotics is essential. The local therapy plays an important part in relieving symptoms and should consist of mild preparations with minimally sensitizing potential.

Temporary henna tattoos.

Today, temporary henna tattoos drawn on the skin are very fashionable and have become more and more popular. At the same time, allergic reactions following these tattoos has increased worldwide. Actually, henna has a very low allergic potential. In most cases, allergic reactions are caused by the mixtures used by the so-called "artists" which contain not only natural henna but also many chemical coloring agents such as diaminotoluenes and diaminobenzenes. The long duration of skin contact, the high concentrations of sensitizing materials, and the lack of a neutralizing agent dramatically increases the risk of skin sensitization. We summarized 31 of our own cases with allergic contact dermatitis due to temporary henna tattoos and outlined the main characteristics for this peculiar contact dermatitis.

Psoriatic erythroderma associated with enalapril.

A 59-year-old man with a 35-year personal and positive family history of psoriasis was admitted to our department for treatment of psoriatic erythroderma. The patient had commenced therapy with enalapril 10 mg b.i.d. for the treatment of hypertension approximately 6 weeks before hospitalization. Five weeks after the initiation of enalapril, his psoriasis began to flare, and for a period of about 1 week it reached the extent of erythroderma. The patient did not associate the psoriatic flare with other factors such as infections, trauma, or stress. The patient presented with diffuse erythema and pronounced desquamation covering his entire trunk, scalp, and extremities (Figure). Nearly 100% of the body surface area was involved. The palms and soles were also affected, displaying erythema, hyperkeratosis, and painful fissures. The nails showed pits, oil spots, and subungual hyperkeratosis. The patient also had psoriatic arthritis affecting the interphalangeal joints of his fingers. Laboratory tests revealed an elevated erythrocyte sedimentation rate, an elevated creatinine level of 180 mmol/L, a blood urea nitrogen level of 10.8 mmol/L, and a uric acid level of 716 mmol/L. Urinalysis showed proteinuria of 1.5 g/24 h. The patient's renal condition was diagnosed as chronic tubulointerstitial nephritis, most probably related to his dermatologic disease. Allopurinol and dietary measures were recommended. Following treatment with methotrexate and replacement of enalapril therapy, the erythema and scaling gradually subsided and became confined to his pre-eruptive chronic plaques (approximately 5% of body surface area). Rechallenge with enalapril was not performed.

Old drug--new indication. Rifampicin in psoriasis.

BACKGROUND: The efficacy of traditional systemic therapies for psoriasis is limited by various side effects, toxicity, drug-drug interactions, and the need for frequent laboratory monitoring. In animal models, rifampicin causes immunosuppression and in conventional doses it suppresses the T-cell function. OBJECTIVE: To show that rifampicin has a therapeutic effect in eruptive psoriasis and to try to explain its mode of action. MATERIALS AND METHODS: A total of 76 patients (34 men and 42 women, aged between 12 and 68 years) with eruptive psoriasis were enrolled in the study. They were divided into two groups according to the evidence of a concomitant streptococcal infection. Rifampicin was administered orally in a 600 mg daily dosage for at least 60 days. Only emollients were given for topical therapy. RESULTS: A statistical (chi-squared test) analysis was done and it could be concluded that improvement in the two groups was statistically indistinguishable (p = 0.892), while comparison with the control group showed a significant difference (p = 0.00082). CONCLUSION: The results express that there is no statistically significant difference between the treating groups and the effect of rifampicin could not be related only to its antimicrobial properties. Its therapeutic effect most probably is due to its immunosuppressive properties.